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School District Information

School District Name
Required

School District Address
Required

City
Required

State
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Zip
Required

Phone
Required! Must be a valid phone number i.e.: 123-456-7890

Fax
Required! Must be a valid fax number i.e.: 123-456-7890

Losses

Has the District ever made claim against a surety or fidelity bond?
Required

If yes, please give a description of the situation and the amount of any payment.
Required

Investments

District Treasurer

Treasurer's Name (First, Middle, Last)
Required

Home Address (Street, City, Zip)
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What other positions does the treasurer hold within the district?:
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Business Phone
Required

Home Phone
Required

Has this person ever been charged with any kind of criminal offense?
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If yes, please describe.
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Request

Bond #
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Date of Last Audit
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Was audit free from criticism?
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Change Bond Amount From
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Change Bond Amount To
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Change District Treasurer From
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Change District Treasurer To
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Other Change
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Bond Amount

(Information from Annual Financial Report)

Receipts/Revenues (Current)
Valid characters: 0123456789 , $

Tax Anticipation Warrants/Notes
Valid characters: 0123456789 , $

Fund Balances
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Total of the above
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Bond Amount Requested
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Applicant Information

CERTIFICATION and SIGNATURE

The undersigned certifies that the information is true, correct and complete to the best of his/her knowledge.

Electronic Signature
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Email
Please specify your email address.

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Security Code
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